<?xml version='1.0' encoding='UTF-8'?>
<ZIMA501 xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="ZIMA501_20262.xsd">
	<Form>
		<Identification>ZIMA501</Identification>
		<FormCreationDate>2021-05-16</FormCreationDate>
		<FormCreationHour>10:08:13.084</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>FA</TypeForm>
		<HandledOriginalForm>
			<Identification>ZIMA001</Identification>
			<FormCreationDate>2021-05-16</FormCreationDate>
			<FormCreationHour>10:05:13.084</FormCreationHour>
			<AttestationStatus>0</AttestationStatus>
			<TypeForm>FA</TypeForm>
		</HandledOriginalForm>
		<CoordinatesContactPerson>
			<Name>Nom</Name>
			<FirstName>Lauren</FirstName>
			<Communication>
				<EmailAddress>Lauren.Nom@skynet.be</EmailAddress>
			</Communication>
		</CoordinatesContactPerson>
		<CoordinatesInformant>
			<UserQuality>1</UserQuality>
			<Denomination>Pubmarket</Denomination>
		</CoordinatesInformant>
		<DclInformation>
			<LanguageCodePdf>1</LanguageCodePdf>
		</DclInformation>
		<RiskIdentification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
		</RiskIdentification>
		<Reference>
			<ReferenceType>5</ReferenceType>
			<ReferenceOrigin>2</ReferenceOrigin>
			<ReferenceNbr>3400000MVY01V</ReferenceNbr>
		</Reference>
		<Reference>
			<ReferenceType>1</ReferenceType>
			<ReferenceOrigin>1</ReferenceOrigin>
			<ReferenceNbr>2005004</ReferenceNbr>
		</Reference>
		<HandledReference>
			<ReferenceType>1</ReferenceType>
			<ReferenceOrigin>2</ReferenceOrigin>
			<ReferenceNbr>34000050QU00N</ReferenceNbr>
		</HandledReference>
		<RiskDetail>
			<RiskStartingDate>2021-05-06</RiskStartingDate>
		</RiskDetail>
		<PreventionService>
			<CompanyID>0</CompanyID>
			<Denomination>Externe preventiedienst</Denomination>
			<CoordinatesContactPerson>
				<Name>Janssens</Name>
				<FirstName>Jan</FirstName>
				<Communication>
					<PhoneNbr>022222222</PhoneNbr>
					<EmailAddress>janjanssens@email.be</EmailAddress>
				</Communication>
			</CoordinatesContactPerson>
		</PreventionService>
		<EmployerDeclaration>
			<Quarter>20181</Quarter>
			<NOSSRegistrationNbr>141137377</NOSSRegistrationNbr>
			<Trusteeship>0</Trusteeship>
			<CompanyID>0</CompanyID>
			<System5>0</System5>
			<HandledEmployerDeclaration>
				<Quarter>20211</Quarter>
				<NOSSRegistrationNbr>042745862</NOSSRegistrationNbr>
				<Trusteeship>0</Trusteeship>
				<CompanyID>0</CompanyID>
				<EmployerDenomination>Gobelijn</EmployerDenomination>
				<EmployerStreet>Steenweg</EmployerStreet>
				<EmployerHouseNbr>157</EmployerHouseNbr>
				<EmployerZIPCode>3454</EmployerZIPCode>
				<EmployerCity>Geetbets</EmployerCity>
				<EmployerCountry>150</EmployerCountry>
				<LegalForm>bvba</LegalForm>
				<ImportanceCode>3</ImportanceCode>
			</HandledEmployerDeclaration>
			<NaturalPerson>
				<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
				<INSS>57040610511</INSS>
				<HandledNaturalPerson>
					<NaturalPersonSequenceNbr>000702</NaturalPersonSequenceNbr>
					<INSS>57040610511</INSS>
					<WorkerName>Robbedoes</WorkerName>
					<WorkerFirstName>Jommeke</WorkerFirstName>
					<WorkerInitial>M</WorkerInitial>
					<WorkerBirthdate>1965-05-25</WorkerBirthdate>
					<WorkerBirthplace>Zonneland</WorkerBirthplace>
					<WorkerBirthplaceCountry>150</WorkerBirthplaceCountry>
					<WorkerSex>2</WorkerSex>
					<Nationality>150</Nationality>
					<OriolusSuccessCode>1</OriolusSuccessCode>
					<OriolusSubStatusRip>0</OriolusSubStatusRip>
					<BisFlagIndication>0</BisFlagIndication>
				</HandledNaturalPerson>
				<WorkerRecord>
					<EmployerClass>036</EmployerClass>
					<WorkerCode>495</WorkerCode>
					<NOSSQuarterStartingDate>2021-01-01</NOSSQuarterStartingDate>
					<NOSSQuarterEndingDate>2021-03-31</NOSSQuarterEndingDate>
					<Border>0</Border>
					<HandledWorkerRecord>
						<EmployerClass>036</EmployerClass>
						<WorkerCode>495</WorkerCode>
						<NOSSQuarterStartingDate>2021-01-01</NOSSQuarterStartingDate>
						<NOSSQuarterEndingDate>2021-03-31</NOSSQuarterEndingDate>
						<Border>0</Border>
						<ActivityCode>22210</ActivityCode>
					</HandledWorkerRecord>
					<Occupation>
						<OccupationSequenceNbr>01</OccupationSequenceNbr>
						<OccupationStartingDate>2003-06-15</OccupationStartingDate>
						<OccupationEndingDate>2021-03-31</OccupationEndingDate>
						<JointCommissionNbr>125</JointCommissionNbr>
						<WorkingDaysSystem>500</WorkingDaysSystem>
						<ContractType>0</ContractType>
						<RefMeanWorkingHours>3800</RefMeanWorkingHours>
						<MeanWorkingHours>3800</MeanWorkingHours>
						<Retired>0</Retired>
						<HandledOccupation>
							<OccupationSequenceNbr>01</OccupationSequenceNbr>
							<OccupationStartingDate>2003-06-15</OccupationStartingDate>
							<OccupationEndingDate>2021-03-31</OccupationEndingDate>
							<JointCommissionNbr>125</JointCommissionNbr>
							<WorkingDaysSystem>500</WorkingDaysSystem>
							<ContractType>0</ContractType>
							<RefMeanWorkingHours>3800</RefMeanWorkingHours>
							<MeanWorkingHours>3800</MeanWorkingHours>
							<Retired>0</Retired>
							<InternalOccupationNbr>3400000S6A01J</InternalOccupationNbr>
							<OccupationValidationCode>100</OccupationValidationCode>
						</HandledOccupation>
						<SeverancePayment>
							<SeverancePaymentStartDate>2021-04-01</SeverancePaymentStartDate>
							<SeverancePaymentEndDate>2022-03-31</SeverancePaymentEndDate>
						</SeverancePayment>
						<RiskDetailOccupation>
							<LastWorkingDayDate>2020-08-04</LastWorkingDayDate>
							<CalculationBaseAllowance>
								<RemunerationTimeUnit>1</RemunerationTimeUnit>
								<PieceTaskServicesCommissionRemunerationBasisAmount>89900</PieceTaskServicesCommissionRemunerationBasisAmount>
								<StableOccupationIndicator>1</StableOccupationIndicator>
								<PartTimeCalculBase>
									<RemunerationTimeUnit>1</RemunerationTimeUnit>
									<PartTimeHourlyGrossSalary>96678</PartTimeHourlyGrossSalary>
								</PartTimeCalculBase>
								<ExceptSituationCalculBase>
									<ExceptSituationMeanWorkingHours>3800</ExceptSituationMeanWorkingHours>
								</ExceptSituationCalculBase>
							</CalculationBaseAllowance>
							<ReferencePeriod>
								<RefStartingDate>2021-05-07</RefStartingDate>
								<RefEndingDate>2021-05-15</RefEndingDate>
								<NatureOfDay>
									<DayIndicator>--05-07</DayIndicator>
									<DayNatureCode>2.4</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-08</DayIndicator>
									<DayNatureCode>2.4</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-09</DayIndicator>
									<DayNatureCode>2.4</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-10</DayIndicator>
									<DayNatureCode>2.4</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-11</DayIndicator>
									<DayNatureCode>1</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-12</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-13</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-14</DayIndicator>
									<DayNatureCode>2.4</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-15</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-16</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-17</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
							</ReferencePeriod>
						</RiskDetailOccupation>
					</Occupation>
				</WorkerRecord>
				<HandledServiceData>
					<DimonaNbr>500043417172</DimonaNbr>
					<ServiceEntryDate>1990-01-02</ServiceEntryDate>
				</HandledServiceData>
			</NaturalPerson>
		</EmployerDeclaration>
	</Form>
</ZIMA501>